Annals for Educators - April 2023
Authors: Christine Laine
Journal: Annals of Internal Medicine (2023)

Web ExclusivesApril 2023Annals for Educators - April 2023FREEChristine Laine, MD, MPHChristine Laine, MD, MPHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202304180 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsSubclinical Coronary Atherosclerosis and Risk for Myocardial Infarction in a Danish Cohort. A Prospective Observational Cohort StudyContemporary Natural History of Coronary Artery DiseaseThe association between image-detected, subclinical coronary atherosclerosis and outcomes is unclear. In this population-based study, compared with persons with no image-detected obstruction, persons with both obstructive and nonobstructive yet extensive disease had significantly higher relative risk for myocardial infarction and death despite the absence of symptoms. The accompanying editorial explains why this study provides unique data on the contemporary natural history of coronary artery disease in the absence of an intervention that will inform prevention strategies.Use this article and the editorial to:Invite a cardiologist or radiologist to your session to review coronary CT images of patients with varying degrees of image-detected obstruction.Review known risk factors for coronary artery disease.Discuss whether and how coronary CT imaging added to risk prediction for the participants in this study.Discuss whether these findings justify routine screening with coronary CT. Would evidence of image-detected obstruction change clinical management?Cardiac Arrest During Delivery Hospitalization. A Cohort StudyCardiac arrest is an uncommon but serious maternal complication. This article describes the rate of cardiac arrest among hospitalized women who were pregnant in the United States in 2017 to 2019 and examines factors associated with those who had cardiac arrest and those who survived.Use this article to:Review how the United States compares with other countries with regard to maternal morbidity and mortality. This article may inform the discussion. Discuss potential reasons that maternal morbidity and mortality are worse in the United States than in other affluent countries.Brainstorm with your learners about things internal medicine physicians can do to improve pregnancy outcomes among their patients who are or become pregnant.Invite a clinician with expertise in advanced cardiac life support to your session to review CPR procedures in pregnant persons.Worsening Spread of Candida auris in the United States, 2019 to 2021Candida auris is an emerging fungal threat that has been spreading in the United States since it was first reported in 2016. This article uses case counts and data on colonization screening and antifungal susceptibility testing to describe changes in the U.S. epidemiology of C auris between 2019 and 2021.Use this article to:Invite an infectious disease specialist to your session to review the clinical presentation, diagnosis, and treatment of C auris infection.Review Figure 3 in the article to determine whether your state is one where C auris is spreading.Discuss strategies that clinicians and health care institutions should use to prevent C auris infection.Effectiveness of Molnupiravir and Nirmatrelvir–Ritonavir in Hospitalized Patients With COVID-19. A Target Trial Emulation StudyWhether hospitalized patients benefit from COVID-19 oral antivirals is uncertain. This target trial emulation study used data from electronic health databases in Hong Kong to examine the real-world effectiveness of molnupiravir and nirmatrelvir–ritonavir in hospitalized patients with COVID-19 during the Omicron outbreak.Use this article to:Review the methods for target trial emulation. How does target trial emulation improve on other observational study designs?Review the results of this study, and discuss the implications for care of patients who might currently be admitted to your hospital with COVID-19. Which patients would you treat with antiviral therapy?How would you choose whether to prescribe molnupiravir or nirmatrelvir–ritonavir?Effect of Thromboprophylaxis on Clinical Outcomes After COVID-19 HospitalizationSeeing the Positive in Negative StudiesThromboembolism is an important complication in hospitalized patients with COVID-19. This trial sought to determine whether extended thromboprophylaxis after hospital discharge would reduce deaths and thromboembolic events. The trial was done during a time when the Omicron and Delta variants were circulating and COVID-19 hospitalization rates were decreasing. The accompanying editorial discusses factors that contribute to the misinterpretation of studies as either positive or negative and how research reporting that focuses on estimation of effects rather than hypothesis testing would help minimize such misinterpretations.Use this article and the editorial to:Review the findings of the study.Was the trial able to answer the question it set out to answer? If not, why not?Read the accompanying editorial, and then discuss the findings in light of their uncertainty and the 95% confidence intervals around the estimate of effect.Discuss why the findings of this and other inconclusive trials are useful and should be reported.Effect of Yoga on Frailty in Older Adults. A Systematic ReviewOlder adults are at greater risk for frailty, which is associated with increased morbidity and mortality. Yoga has been studied for its benefits on different aspects of aging and health promotion. This systematic review examined the effects of yoga practice on different domains of frailty in older adults.Use this article to:Review the brief video summarizing the results of the review with your learners. Ask your learners to define frailty. This editorial may help guide the discussion. Go over the findings of the review, and discuss how the evidence summarized in the article might inform how we advise patients who are interested in strategies to mitigate frailty as they age.Invite a yoga instructor to your session to discuss the type of yoga regimens he or she typically recommends for older persons who are physically inactive.Beyond the GuidelinesHow Would You Manage This Patient With Benign Prostatic Hyperplasia? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterSymptomatic benign prostatic hyperplasia (BPH) is common in middle-aged and older patients assigned male sex at birth, regardless of their gender identity. In this article, an internal medicine physician and a urologist discuss the care of a patient with lower urinary tract symptoms, with reference to the American Urological Association's 2021 guidelines on BPH.Use this article to:Watch the patient video with your learners, and then ask them what they would recommend for this patient with BPH.Review the American Urological Association's 2021 guidelines on care of patients with BPH (available here and here). Review the potential benefits and harms of pharmacologic therapy for BPH. What factors should promote caution in prescribing these agents?Review the potential benefits and harms of surgical therapy for BPH. What factors should promote caution in recommending surgery?Have your learners test their knowledge by completing the quiz that accompanies the article.Periprocedural AnticoagulationManagement of patients taking anticoagulants around the time of procedures is a common and complex clinical scenario. Providing evidence-based care requires estimation of risk for thrombosis and bleeding, knowledge of commonly used medications, multidisciplinary communication and collaboration, and patient engagement and education. This review provides a standardized, evidence-based approach to periprocedural management of anticoagulation, based on current evidence and expert clinical guidelines.Use this article to:Ask your learners to list at least 5 common scenarios in which decisions need to be made about management of periprocedural anticoagulation. Poll the group to see who would continue anticoagulation in each scenario.Review procedures during which it is typically safe to continue anticoagulation.Review procedures during which it is typically necessary to interrupt anticoagulation.If anticoagulation needs to be interrupted, how would you do this for patients using warfarin and for patients using direct oral anticoagulants?Test your learners' knowledge by having them complete the quiz that accompanies the article and then reviewing the correct answers.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Christine Laine, MD, MPHFrom the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. 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